MEDICAL, DENTAL, VISION, HEARING, OR BEHAVIORAL …



FORMTEXT ? Medical, Dental, Vision, Hearing, or Behavioral Health AppointmentPurpose: Use this form to document medical, dental, vision, hearing and behavioral health (Child and Adolescent Needs and Strengths assessment (CANS)) appointments. Completion of this form meets requirements in: Residential Child Care Licensing Minimum StandardsResidential Child Care ContractsChild Protective Services policy Completion of this form is not required for allied health services such as physical therapy, occupational therapy, speech therapy, or dietary services.Directions: The person taking the child or youth completes Section I of this form on each visit with a health care provider. When possible, Section II is completed by the health care provider. If the health care provider is unable to complete Section II, the person taking the child or youth to the appointment completes Section II, signs his or her name, and checks the box labeled: health care provider unable to complete. The health care provider may attach medical records or other information to this form in lieu of completing Section II.The caregiver provides a copy of the completed form to the CPS caseworker to file in the case record.SECTION I. CHILD'S INFORMATION FORMTEXT ?Child’s Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Person Identification (PID) Number: FORMTEXT ?????Appointment Date: FORMTEXT ?????CAREGIVER INFORMATION FORMTEXT ?Caregiver can be a foster parent, relative, non-relative, or representative of a residential operation who is taking the child to the health care provider.Caregiver’s Name: FORMTEXT ?????Phone: FORMTEXT ?????Agency: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????CASEWORKER INFORMATION FORMTEXT ?Caseworker’s Name: FORMTEXT ?????Phone Number: FORMTEXT ?????Fax: FORMTEXT ?????REASON FOR VISIT FORMTEXT ? FORMTEXT ?? 3-Day Medical Exam. (Required within three business days of removal with some exceptions, such as DFPS removal while child is in a hospital setting). FORMTEXT ?? Child or Youth with Primary Medical Needs. (Required within seven days before or three days after placement date). FORMTEXT ?? Initial Child and Adolescent Needs and Strengths (CANS) Assessment. (Required within 30 days of entering DFPS conservatorship). FORMTEXT ?? Child and Adolescent Needs and Strengths Update (CANS) Assessment. (Required annually; may be required more frequently in some areas). FORMTEXT ?? Routine Texas Health Steps Medical Checkup. (Required at the following ages: within five days after discharge from the hospital, at 2 weeks of age, at 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, 36 months, and then annually). FORMTEXT ?? Other Medical Checkup. Reason: FORMTEXT ????? FORMTEXT ?? Initial Texas Health Steps Dental Checkup. (Required within 60 days of entering DFPS conservatorship if the child is 6 months of age or older, or within 30 days of turning age 6 months). FORMTEXT ?? Initial Texas Health Steps Medical Checkup. (Required within 30 days of entering DFPS conservatorship). FORMTEXT ?? Routine Texas Health Steps Dental Checkup. (Required every six months or as recommended by a dentist). FORMTEXT ?? Other Dental Checkup. Reason: FORMTEXT ????? FORMTEXT ?? Vision Check FORMTEXT ?? Hearing Check FORMTEXT ?? ER Visit – Reason: FORMTEXT ????? FORMTEXT ?? Specialty Visit: Reason: FORMTEXT ????? FORMTEXT ?? Illness, injury or accident or other follow-up visit. (Describe the injury, accident or illness, including the date and time of the incident.) FORMTEXT ?????MEDICATIONS FORMTEXT ? FORMTEXT ?? No FORMTEXT ?? Yes (List) Caregiver Comments:MedicationDosagePrescribed forInstructions FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Caregiver Comments: FORMTEXT ?????SIGNATURE OF PERSON COMPLETING SECTION i FORMTEXT ?DFPS Staff or Caregiver Signature:X FORMTEXT ?????Date Signed: FORMTEXT ?????SECTION II. HEALTH CARE APPOINTMENT (TO BE COMPLETED BY HEALTH CARE PROVIDER) FORMTEXT ?Child or Youth’s Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Appointment Date: FORMTEXT ?????VISIT RESULTS FORMTEXT ? FORMTEXT ?? Child or youth refused appointmentVITALS:Years: FORMTEXT ?????Months: FORMTEXT ?????Weeks: FORMTEXT ?????Temperature: FORMTEXT ?????Pulse: FORMTEXT ?????Respirations: FORMTEXT ?????Blood Pressure: FORMTEXT ?????Height: FORMTEXT ????? %: FORMTEXT ?????Weight: FORMTEXT ????? %: FORMTEXT ?????Head Circumference: FORMTEXT ????? %: FORMTEXT ?????BMI: FORMTEXT ????? %: FORMTEXT ?????VISION SCREEN: FORMTEXT ?? Not done FORMTEXT ?? Child or youth unable to comply with screening FORMTEXT ?? Refused500100020004000R FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????L FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DIAGNOSES: FORMTEXT ?? Well Child or No Dental Problems FORMTEXT ?? Other (list): FORMTEXT ????? NEW OR CHANGED MEDICATIONS ONLY: FORMTEXT ?? No Medication Changes NameDosagePrescribed forInstructionsDiscontinued NewChanged FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?? FORMTEXT ??VACCINES: Children and youth are prohibited from receiving vaccinations at the 3-Day Medical Exam unless an emergency situation requires tetanus vaccination. FORMTEXT ?? None Administered FORMTEXT ?? DTap FORMTEXT ?? DT FORMTEXT ?? Tdap FORMTEXT ?? HIB FORMTEXT ?? PCV FORMTEXT ?? Td FORMTEXT ?? MMR FORMTEXT ?? Varicella FORMTEXT ?? Hep A FORMTEXT ?? Hep B FORMTEXT ?? IPV FORMTEXT ?? HPV FORMTEXT ?? MCV FORMTEXT ?? Rotavirus FORMTEXT ?? Influenza FORMTEXT ?? Pneumovax FORMTEXT ?? Other (list): FORMTEXT ?????REFFERRED TO: FORMTEXT ?? None Necessary FORMTEXT ?? ECI (Early Childhood Intervention) FORMTEXT ?? Speech Therapy FORMTEXT ?? Occupational Therapy FORMTEXT ?? Physical Therapy FORMTEXT ?? Specialist (Type): FORMTEXT ????? FORMTEXT ?? Other (Type) FORMTEXT ?????FOLLOW-UP: FORMTEXT ?? None Necessary FORMTEXT ?? Return Visit: When and Why FORMTEXT ?????Provider Comments: FORMTEXT ?????PROVIDER INFORMATION FORMTEXT ?Provider Signature:X FORMTEXT ?????Clinic Name: FORMTEXT ?????Phone: FORMTEXT ?????Printed Name: FORMTEXT ?????Address: FORMTEXT ?????Fax: FORMTEXT ?????Date Signed: FORMTEXT ?????City, State, Zip FORMTEXT ?????If Section II is not completed by a medical or dental provider, the caregiver sign below.Caregiver Signature:X FORMTEXT ?????Date Signed: FORMTEXT ????? FORMTEXT ?? The health care provider was unable to complete this form.PRIVACY STATEMENT FORMTEXT ?DFPS values your privacy. For more information, read our Privacy and Security Policy. FORMTEXT ? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download